Laparoscopic and open colorectal surgery: a prospective cost analysis.

AIM: Cost has been perceived to be a factor limiting the development of laparoscopic colorectal surgery. This study aimed to compare the costs of laparoscopic and open colorectal surgery. METHOD: Patients undergoing laparoscopic or open elective colorectal surgery were recruited into a prospective study to evaluate the healthcare costs of each operative procedure in a district general hospital in England. All healthcare resources used (operation, hospital and community) were recorded and converted to costs in British pounds, 2006-2007. Costs of laparoscopic and open surgery were compared. RESULTS: In all, 201 consecutive patients consented and were recruited (131 laparoscopic, 70 open). Operative costs were greater in the laparoscopic group (£2049 vs£1263, P < 0.001) due to the costs of disposable instruments, but the hospital costs were less (£1807 vs£3468, P < 0.001) due to longer lengths of stay in the open group. Community costs were similar in the two groups and had little impact on the overall costs, which were not significantly different (£3875 laparoscopic vs£4383 open, P = 0.308). In the subgroup of patients with a stoma, overall costs in the laparoscopic group are higher (not significant). CONCLUSION: The costs of laparoscopic and open colorectal surgery are broadly equivalent. If there is an associated improvement in patient benefit, then laparoscopic colorectal surgery may be considered to be cost effective compared with open surgery.

Laparoscopic excision of rectovaginal endometriosis: report of a prospective study and review of the literature.

AIM: The surgical management of rectovaginal endometriosis is challenging. We present our experience of the laparoscopic management of these difficult cases, together with a review of the current literature. METHOD: A prospective database was established for all patients undergoing surgery for Deep Infiltrating Endometriosis (DIE) with rectovaginal and/or ureteric and bladder nodules. Outcomes analysed include operation performed, conversion and complication rates, and length of stay. These outcomes were compared with other laparoscopic rectal resections for alternative diagnoses recorded in the database and with outcomes seen in a literature review of studies on the surgical management of endometriosis. RESULTS: Between April 2004 and November 2007, 54 patients underwent laparoscopic excision of rectovaginal endometriosis by a combined colorectal and gynaecological surgical team. Out of the 54 patients, 37% of patients underwent a rectal wall shave, 13% had a disc excision of the rectal wall, and 50% underwent segmental resection. There was a conversion rate of 4%, median duration of stay was 3 days, with 2% requiring transfusion. Major complications occurred in 7% of patients, with 4% requiring reoperation. Patients undergoing segmental resection for endometriosis had a higher complication rate than those having surgery for other diagnoses. There was an increased incidence of anastomotic stenosis, with histopathological results suggesting that the disease process might have contributed to this occurrence. CONCLUSIONS: Laparoscopic resection of rectovaginal endometriosis may be associated with a higher incidence of complications than resections performed for other diagnoses.

A systematic review of postoperative analgesia following laparoscopic colorectal surgery.

OBJECTIVE: The use of epidural analgesia is considered fundamental in Enhanced Recovery Protocols. However its value in the perioperative management of laparoscopic colorectal surgical patients is unclear and analgesic regimens vary. The aim of this systematic review was to examine the effects of various analgesic regimes on outcomes following laparoscopic colectomy. METHOD: A systematic review of studies assessing analgesic regimes following laparoscopic colorectal resection was performed. The primary outcome of interest was length of hospital stay whilst the secondary outcomes included pain, time to tolerate a normal diet, return of bowel function and postoperative complications. RESULTS: Eight studies were identified, five of which compared epidural vs patient controlled analgesia/intra-venous morphine. There were no significant differences between the groups in terms of outcomes, except pain control which was superior in the epidural group. Spinal anaesthesia using intrathecal morphine in addition to local anaesthetic, and the use of nonsteroidal anti-inflammatory agents have also been shown to reduce postoperative pain. CONCLUSION: There is a paucity of data assessing the benefits of postoperative analgesic regimes following laparoscopic colorectal surgery and none of the protocols were shown to be clearly superior. Further studies, including the assessment of spinal analgesia are required to determine the most appropriate analgesic regime following laparoscopic colorectal surgery.

The uptake of laparoscopic colorectal surgery in Great Britain and Ireland: a questionnaire survey of consultant members of the ACPGBI.

OBJECTIVE: The National Institute for Clinical Excellence (NICE) has recommended laparoscopic resection as an alternative to open surgery for patients with colorectal cancer. The aim of this study was to evaluate the current uptake of laparoscopic colorectal surgery in Great Britain and Ireland. METHOD: A questionnaire was distributed to members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) regarding their current surgical practice. Results were analysed individually, by region, and nationwide. RESULTS: Information was received on 436 consultants (in 155 replies), of whom 233 (53%) perform laparoscopic colorectal procedures. During the previous year, 25% of colorectal resections were performed laparoscopically by the respondents. However, of those surgeons who were performing laparoscopic resections, only 30% performed more than half of all their resections laparoscopically. Right hemicolectomy, left-sided resections, and rectopexy were the most frequently performed laparoscopic resections. There was an even distribution throughout the country of consultants performing laparoscopic resections (regional IQR 48-60%). The main reason for consultants not performing laparoscopic procedures was a lack of training or funding. CONCLUSION: Laparoscopic colorectal surgery is being performed by more than half (53%) of colorectal consultants nationwide, although only a quarter of all procedures are being undertaken laparoscopically.

Systematic Review of Quality of Life following Laparoscopic and open colorectal surgery.

OBJECTIVE: To compare the health-related quality of life (HRQoL) of patients following laparoscopic and open colorectal surgery. METHODS: A systematic review was performed according to Quorum guidelines. Prospective studies comparing the HRQoL of patients after laparoscopic and open colorectal surgery were identified. The primary outcome measure was postoperative quality of life; performance status and cosmesis were secondary outcome measures. RESULTS: 23 studies were identified that satisfied the inclusion criteria; 18 assessed HRQoL, 4 performance status, and 3 cosmesis. It was not possible to perform a meta-analysis due to study heterogeneity. The studies reported outcomes for 2946 patients. The most frequent HRQoL instruments employed were SF-36, EORTC, and GIQLI. 6 studies, using a total of 12 separate measures, evaluated QoL during the first 3 post-operative months: 10 of these measures showed no significant difference, and 2 showed an improved HRQoL with laparoscopy. Twelve further studies evaluated HRQoL up to 5 years post-operatively: 9 showed no difference between the 2 groups, and 3 demonstrated a benefit for laparoscopy. Three of 4 studies assessing performance status on discharge, and all 3 studies assessing cosmesis, reported benefits with the laparoscopic approach. CONCLUSIONS: The current evidence suggests there is no significant difference in HRQoL following laparoscopic and open colorectal surgery, although there is a lack of good quality data. There is a trend towards improved quality of life outcomes and performance status with laparoscopy in the early post-operative period. There is a need for further research, particularly assessing quality of life in the early post-operative period.

Reduced adhesion formation following laparoscopic versus open colorectal surgery.

BACKGROUND: Adhesion formation is common after abdominal surgery. This study aimed to compare the extent of adhesion formation following laparoscopic and open colorectal surgery. METHODS: An observational study was undertaken to identify adhesions in patients undergoing laparoscopy after previous laparoscopic or open colectomy. Adhesions were scored according to a system validated for interobserver (median kappa = 0.80) and intraobserver (kappa = 0.82) agreement. The primary endpoint was the overall adhesion score (0-10); a secondary endpoint was the adhesion score at the main incision site (0-6). RESULTS: Forty-six patients were recruited (13 laparoscopic and 33 open colectomy). In most patients (n = 29), laparoscopy was performed for tumour staging before liver resection. The median (interquartile range) overall adhesion score was 7 (5-8) in the open group and 0 (0-3) in the laparoscopic group (P < 0.001). A similar difference was found for the main incision score: 6 (4-6) versus 0 (0-0) (P < 0.001). CONCLUSION: There may be a reduction in adhesion formation following laparoscopic compared with open colectomy, although the small sample size limits this conclusion.

Laparoscopic colorectal surgery - results from 200 patients.

OBJECTIVE: Laparoscopic surgery is increasingly being performed for benign and malignant colorectal disease. This study examines the short-term results in a consecutive series of laparoscopic colorectal procedures performed over 2 years. METHOD: A prospective database was established for all elective patients undergoing laparoscopic colorectal surgery by one surgeon. The main outcome measures assessed were operative duration, conversion rate, length of hospital stay, morbidity and mortality and lymph node harvest. RESULTS: Two hundred and thirty-one consecutive patients were referred for elective colorectal surgery, with 18 patients excluded from laparoscopic surgery. Thirteen patients had nonresective laparoscopic colorectal procedures for endometriosis and have been excluded from the series. Of 200 patients who underwent a laparoscopic colorectal procedure, 114 (57%) were female, the median age was 67 years (inter-quartile range (IQR) 57-76), and there were 116 malignancies. The most common operations were anterior resection and sigmoid colectomy (n = 82), right hemicolectomy (n = 62) and left hemicolectomy (n = 12). The median operating time was 120 min (IQR 90-150) and 10 patients (5%) required conversion to open surgery. The median lymph node harvest in malignancies was 21 nodes (IQR 15-30) and no positive resection margins were found. There were two deaths and 29 significant complications (14.5%), with seven patients requiring re-operations because of postoperative complications. The median postoperative hospital stay was 4 days (IQR 3-6) and 13 patients (6.5%) were re-admitted within 30 days of hospital discharge. CONCLUSION: Laparoscopic colorectal surgery is possible for most benign and malignant conditions, with low conversion and complication rates, as well as short hospital stay.

The acute management and surgical reconstruction following failed esophagectomy in malignant disease of the esophagus.

The stomach is the favored organ for reconstruction following esophageal resection for malignant disease, but has a 2% failure rate relating to ischemia. This event is associated with a high mortality, although appropriate surgical management with removal of the conduit can be life-saving. Further reconstruction is very challenging. We discuss the management options and surgical techniques for these patients. We reviewed of the surgical management of seven patients referred to a tertiary center over a 2-year period with failure of their primary esophageal reconstruction. Four patients had reconstruction with jejunum (2 free transfers and 2 'supercharged' pedicles with microanastomosis in the neck), and three with left colon. The route of reconstruction was substernal in four patients, subcutaneous in two, and through the left pleural cavity in one. There was 0% mortality, and 57% morbidity. The median intensive care unit stay was 2 days (mean 8, range 1-42). All patients tolerated full enteral nutrition, and had a satisfactory functional outcome. Failure of the conduit post-esophagectomy is a rare but serious complication, and these patients require complex surgical reconstruction. The surgical techniques described require a specialist multidisciplinary approach, but good clinical and functional outcomes are possible, even in patients with an underlying malignancy.